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• � APPLICATION FOR PSIZ1diT ?4 , SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES QS- qo7 rSwal :. ENVIRONMENTAL HEALTH DIVISION to20 445 N SAN JOAQUIN, PHONE (209)468-3420 tow _ � a� _ P 0 BOX 2009, STOCKTON, CA 95201 [�5 PERMIT EXPIRES 1 YEAR FROM DTE i SU (Complete in Triplicate) Application is hereby made to San Joaquin County for3a permit to construct and/or install the work herein described. This application is made in compliance with Stan Joaquin County Ordinance No. 549 and 1862 and the Rules sad Regulations of San Joaquin County Public HealthlServices. ' Job Address CiIy/AL4-- ,— Lot Size/Acreage it ' Owner's Name' tx v�2Slrf�l �^ Bye 110% ddress S r t�l t h / "' R c —� Phone Conttacttx -��C1lddress k+ f a License No:,1��--�- �> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well Cl PUMP IINSTALLA�T�ION, {�© SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ `+ fw DISTANCE TO NEAREST: SEPTIC TANK � — SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL iW PITS/SUMPS if INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ii I. C1 Industrial C] Open Bottom ❑ Manteca ; Dia. of Well Excavations` Dia. of Well Casing r: k< upkoomestic/piivate L;"ravel Pack ❑ Tracy 5 Type of Casing_ Specifications I'1 Public CA Other Cl Delta Depth of Grout Seal' l� f Ty of Grout t 4 it / b, �i rz • i ` I I Irrigation -,2 Approx. Depth t I Eastern �- Surface Seal Installed by. - i; Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material A Depth V!�� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 1\\\? available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: 'Number of bedrooms Character of sol to a depth of 3 feet: Water table depth ` SEPTIC TANK. ❑ Type/Mfg, ` Capacity No. CorlmA PKG. TREATMENT PLT.CI Method.g�f/��i�,�� a D Distance to nearest: Well E Foundation Property Line �{ LEACHING LINE CI No. & Length of lines " Total length/size FILTER BED ❑ Distance to nearest: Well = Foundation Proper{q"1 ►-rc� n WSERVIEES 41 ENVIRONMENTAI HEN 1H D.I.u.1.SI.9N SEEPAGE PITS 11 Depth Size Number } SUMPS Ll Distance to nearest: Well I> Foundation Property Line DISPOSAL PONDS 0 i, at the work wilt be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that 1 have prepared this application and th ,r rules and regulations of the San Joaquin County i, Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to:become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ' The applicant trust call for ailregcifi ed inspections. Complete drawing on reverse side. �Lt �� r'L .C' Title: . Signed Dote: �4 li FOR DEPARTMENT USE ONLY Application Accepted by Date-, , 4 Pit or Grout Inspection by h Date Final Inspection by Aa4c& 6 Date A Additional Comments: 0I LSI u Ei r Applicant - Retu n alll`copfes to: San Joaquin County Public Health Services � Environmehtal Health Permit/Services { t 445 N Sana Joaquin, P O Box 2009, Stkn, GA 95201 FEE AMOUNTeOUE AMOUNT REMITTED I CK 8 CASH RE FIVED BY DA/TE PERMIVN0. INFO �/ ^ i EH t]-z.uEv.,i�slN� gyt1(% }� ,1 EH 14-36 v